Report of 24 Cases of Myocardial Infarction Treated at Home

During a four-year period in one general practice 50 patients suffered myocardial infarction; 24 were dead before their general practitioner saw them. Of the surviving 26, 2 were admitted to hospital for social reasons and the others were treated in their homes.One woman suffered a pulmonary embolus on the tenth day of her illness and was admitted to hospital. Three patients were found to develop arrythmias; one of these died. One other patient died, but the others made uneventful recoveries.These results compare well with those obtained by specialist units, perhaps because the advantages of such a unit are balanced by the hazards of transportation to it.     

Shuttle case records: link between general practice and the specialist unit.

General practitioners have participated in the long term follow up of 367 patients who have undergone treatment with potent antirheumatic drugs at this hospital. Over the past two and a half years we have used the "shuttle case record" system, whereby patients'' records are mailed back and forth between our department and general practitioners. This seems to work well. It is safe for the patients, and they save time and money in travel. The general practitioners like it, it improves communication between them and the specialist unit, and it enables the specialist unit to use its resources and manpower more effectively. The system may also be used to monitor patients with other chronic disorders, and it may be a valuable tool for doing research in general practice.     

The consultation process and physician satisfaction: review of referral patterns in three urban family practice units.

To improve communication in the referral process a standard referral form was composed that seeks to involve the patient in the referral process. It has been well received by the consulted physicians, the family practitioners who use it in everyday office parctice and the patients. A review of referral patterns in general practice showed many similarities from practice to practice and from country to country. Ophthalmologists were the most frequently consulted, followed by obstetricians and gynecologists, general surgeons, otolaryngologists and orthopedic surgeons. A follow-up assessment of referral outcome revealed a poor response from the teaching clinics of one tertiary-care hospital to the referring physicians. This resulted in a substantial decrease in the proportion of patients referred from one family practice unit to the hospital over a 3-year period.     

Study of patients' psychological attitudes to a coronary care unit

Seventy-four consecutive male patients aged 38 to 63 years were admitted to a coronary care unit with their first myocardial infarction. Their attitude to the unit was studied by interview and personality tests. Only six patients found the unit anxiety-provoking. Dependency feelings were found to occur frequently, both after transfer from the unit to the general wards and after discharge from hospital. It is suggested that the weaning process from the unit should be gradual and that at least one follow-up outpatient appointment should be arranged, as well as good liaison between the family doctor and the hospital.     

The Planning and Operation of an Intensive Care Unit

It is desirable that every hospital of 100 beds or more should have an intensive care unit. An attempt is made to outline the more important features to be considered, including the physical aspects, when planning and establishing such a unit. The unit should contain 2-4% of the total number of hospital beds. It should be separate, centrally located and self-contained. Direct observation of all patients must be possible at all times. Efficient and specially trained personnel using modern and special equipment are required. Orientation lectures and demonstrations must be carried out frequently and regularly. The types of patients to be admitted to the unit are discussed, as well as the governing rules and regulations. All doctors should have a right to admit and look after their own patients in the unit; an Intensive Care Unit Committee made up of representatives of the major services is suggested as a means of controlling admissions and discharges and for general administration.     

Self-care program for inpatients in a mental hospital.

Summary: A self-care program for selected inpatients in a mental hospital has been developed and has been in operation for more than a year. The 12-bed unit operates without any nursing or other professional staff during the night and weekend. Certain factors, including the mental hospital as an organization, tend to hamper the development of this type of program as well as the progress and growth of other programs in psychiatric hospitals. It is suggested that the much needed progress in the mental hospital would be facilitated by an open-systems approach to its organization. Mental hospitals should consider the introduction of self-care programs for selected patients, mainly in view of their therapeutic potential, but also because of the financial savings such programs offer.     

SUICIDE PROBLEMS IN MEDICAL PRACTICE

Increasing awareness by physicians in general medical practice of the possibility of suicide in nonpsychiatric patients is indispensable for the evaluation of suicide risk and for a practical approach to the problem of prevention.An analysis was made of the records of 11 cases of suicide by medical and surgical patients who were in a general nonpsychiatric Veterans Administration hospital for evaluation and treatment of physical disease.It was noted that the general hospital staff had a low index of suspicion of the possibility of suicide in general hospital patients.It appeared from this study that there is a definite suicide risk in older persons hospitalized for physical illness who develop psychotic reactions during the course of their illness and hospitalization. The signs and symptoms of toxic and organic psychosis in these older patients were not recognized and their significance relative to suicide risk was not appreciated. Although psychiatric signs of severe emotional disturbance appeared clinically obvious at least 24 hours before suicide in ten of the eleven patients, no suicide risk was considered present, nor were adequate precautions taken by the hospital staff. This was owing to the lack of psychiatric orientation among the nonpsychiatric physicians.     

General internal medicine reappears in the teaching hospital: the experience of the Royal Victoria Hospital.

The internal medicine unit of the Royal Victoria Hospital in Montreal was created in 1979 to improve the training of residents and the care of patients. The practices of four internists were brought together in one part of the institution, and within 2 years there were 10 attending staff and 6 residents. The unit now provides continuing care for 2500 patients, many of whom have multisystem or potentially lethal problems. Residents and attending staff share the responsibility of providing 24-hour coverage. The group handles 5000 outpatient visits per year (20% of them being consultations) and provides a general medical consulting service for other hospital departments, with about 300 consultations per year. The creation of the unit, with highly visible role models, appears to have given new prestige to general internists in the hospital. The unit has served as a model for the reorganization of the other medical clinics and provides a base for research in health care delivery.     

Comparative Study of District and Community Hospitals

Opinions conflict on whether there is a place in the Health Service for general practitioner (community) hospitals in which the patients'' treatment is mainly the responsibility of their family doctors. The authors therefore analysed a sample of the patients admitted in the course of a year to a group of two general district hospitals with a comparable sample of the patients admitted to a general practitioner hospital. The aim was to analyse the type of care provided in the general practitioner hospital, to assess whether it was appropriate for the type of cases treated, and to decide whether the patients would have been better off in the district general hospital (and vice versa). The main conclusions are that a district hospital is best for serious illnesses needing skilled decisions and assessments but that most of the work of these hospitals is not of this kind and a community hospital staffed by general practitioners offers many advantages to patients—provided the work being done is constantly under critical assessment. The authors plead for special refresher courses under the N.H.S. for general practitioners working in community hospitals.     

Home care for patients with suspected myocardial infarction: use made by general practitioners of a hospital team for initial management.

Two hundred and sixty three general practitioners were offered the use of a hospital based service consisting of a medical senior house officer, a nurse attached to a coronary care unit, and a specially equipped ambulance estate car to help with the initial management of patients with suspected myocardial infarction who might be suitable for home care. One hundred and sixty nine general practitioners registered as potential users of this service; during 22 months they called the hospital team to see 271 patients, 235 of whom the team suspected had indeed suffered a myocardial infarction. During the same period, however, these general practitioners also admitted 317 patients with suspected myocardial infarction directly to hospital. Other general practitioners admitted 323 patients and deputising doctors 258. A further 529 patients with suspected infarction were admitted without the intervention of a general practitioner. Of the patients seen by the team, 54 required immediate admission to hospital; 17 of the remaining patients who initially appeared suitable for home care later required admission to hospital. In a large city such as Nottingham the provision of hospital based facilities to help general practitioners with home management is unlikely to make an appreciable impact on the overall pattern of care of patients with suspected myocardial infarction.     

Children in Adult Intensive Therapy Units

From experience in the Northampton/Kettering area 9 to 10% of all patients in a general hospital requiring care in an intensive therapy unit were aged 12 years or under. Fifty-nine children were admitted to the intensive therapy unit of Northampton General Hospital between May 1967 and August 1969. Of these, 22 had been injured in road traffic accidents, five were surgical emergencies, five had meningitis, four status epilepticus, and four respiratory infections.All of the 30 families interviewed were in favour of their child being admitted to the unit, and none considered that the experience had had any lasting adverse psychological effect on the child. It is suggested that certain carefully selected child patients do benefit from the facilities of an intensive therapy unit, and for this reason such units must be designed, equipped, and staffed with this in mind.     

Programmed investigation unit.

The programmed investigation unit (PIU) is a inpatient unit where a full range of investigational medicine can be organised. It provides the basic minimum nursing care and is suitable for ambulant patients who can care for themselves. Requests for admission to the PIU at the Royal Victoria Infirmary, Newcastle upon Tyne, come directly from clinical units, and the staff of these units perform some of the tests and remain responsible for the patient while she is in the unit. At present the unit caters only for female medical patients. The average waiting time for admission is three weeks, and because the unit now deals with most investigations the waiting time for admission to the female general medical wards has fallen considerably. The staff of the unit have gained expertise in diagnostic methods, while the nurses of general medical wards have been free to concentrate on nursing those patients who need it. Separating patients who need investigations from those on general medical wards seems a logical way of using resources and staff to best effect.     

Contribution of a General-practitioner Hospital

A properly functioning general-practitioner hospital with good facilities including visiting consultants can greatly lighten the work load of the district general hospital. A general-practitioner hospital is described, run entirely by general practitioners, which cares for over 70% of the inpatients of a group practice. It deals with 98% of all who attend casualty, and carries out almost all of its x-ray work. Its facilities reduce the estimated demand for outpatient appointments at the district general hospital by almost half.The social advantages of a general-practitioner hospital are obvious, and there may be economic advantages as well. Moreover, such a hospital increases the attractiveness of general practice and improves its quality. It is suggested that the general-practitioner hospital is good for the patient, the community, and the doctor—and even the Treasury. There is room for many more.     

Contribution of general practitioner hospitals in Scotland.

The results of a survey of 64 Scottish general practitioner hospitals showed that in 1980 these hospitals contained 3.3% of available staffed beds in Scotland; 13.6% of the resident population had access for initial hospital care, and 14.5% of Scottish general practitioners were on their staffs. During the year of the survey they discharged 1.8% of all non-surgical patients, treated almost 100 000 patients for accidents and emergencies and 140 000 outpatients, and 4.4% of all deliveries in Scotland were carried out in the hospitals surveyed. Most communities which are served by general practitioner hospitals in Scotland are rural and on average are more than 30 miles from their nearest district general hospital. The contribution that these small hospitals make to the overall hospital workload has not previously been estimated. It has been shown nationally to be small but not inconsiderable . In terms of the contribution to the health care of the communities they serve it cannot and should not be underestimated.     

Geriatric medicine in Hull: a comprehensive service.

A partially age-related admission policy coupled with a "single-ward" scheme for treatment and rehabilitation was introduced by the Hull geriatric department in 1970. With rare exceptions, elderly patients needing hospital care have been admitted directly to the geriatric unit, and the proportion of the retired population admitted by the general physicians has been greatly reduced. The proportion of inpatients needing continuing care has been reduced to less than 20%, the mean length of inpatient stay has fallen to under 30 days, and separate long-stay wards are no longer needed. More than 91% of patients are admitted without preceding domiciliary assessment, and only 5-6% of admissions are transferred from other units within the area.     

稻纵卷叶螟种群系统动态模拟

本文组建了稻纵卷叶螟种群系统模似模型,它由系统亚模型和总模型二个部分组成.系统亚模型包括发育、死亡和繁殖三个子模块.系统总模型是作者提出的新模型,它综合了前人所提出的种群模型的优点,以差分方程形式给出,以生理时间为单位,考虑了种群内个体间发育速率的差异,不仅能模拟种群数量动态,而且能模拟种群年龄结构,同时能预测发生期.模型有效性检验表明,模拟结果基本上能吻合实测结果.文中还对5个影响因子进行了灵敏性分析.     

Statistical Approach to Planning an Integrated Haemodialysis/Transplantation Programme

A mathematical model has been constructed to assist in planning the future requirements of a combined haemodialysis and transplantation centre. It has been used to predict the number of patients in the dialysis unit, the general wards, and at home on dialysis, as well as providing further information on transplantation rates and overall costs. The model can be adapted for units with different facilities from our own.It can be primed with data from an individual unit or with pooled data from the whole country. The purpose of this paper is to demonstrate the methodology of a particular statistical approach.     

Microcomputer system in an accident unit.

A microcomputer-based records system has been developed for use in the accident unit of a district general hospital. Patient details are entered directly at the reception desk and the computer generates a casualty card that is updated after the patient has been seen by the doctor, who determines the diagnosis to be recorded and specifies the injury coding. Information is stored on floppy discs, each holding the details of 3400 patients. The computer is used to produce a daily log-book of attendances, including revisits. The stored data may be examined and analysed for both administrative and medical purposes. The work load can be rapidly analysed according to various options that include the nature, type, and site of injuries. The system was introduced in December 1980. Location within the unit allows control over its operation, and many of the limitations of a manual system have been overcome.     

Trauma services requirements in a district general hospital serving a rural area.

OBJECTIVE--To assess the demands made on a regional trauma centre by a district trauma unit. DESIGN--Two part study. (1) Prospective analysis of one month''s workload. (2) Retrospective analysis of one year''s workload by using a computer based records system. Comparison of two sets of results. SETTING--Accident unit in Gwynedd Hospital, Bangor. PATIENTS--(1) All patients who attended the accident unit in August 1988. (2) All patients who attended the accident unit in the calendar year April 1988-April 1989. MAIN OUTCOME MEASURE--Workload of a district trauma unit. RESULTS--In August 1988 there were 2325 attendances; 2302 of these were analysed. In all, 1904 attendances were for trauma; 213 patients were admitted to the trauma ward and 103 required an operation that entailed incision. Patients who attended the unit had a mean (range) injury severity score of 2-13 (0-25). Only two patients had injuries that a district general hospital would not be expected to cope with (injury severity score greater than 20). In the year April 1988-April 1989, 21,007 patients attended the unit. In all, 17,958 attendances were for orthopaedic injuries or injuries caused by an accident; 1966 patients were admitted to the unit. CONCLUSIONS--Most trauma is musculoskeletal and relatively minor according to the injury severity score. All but a few injuries can be managed in district general hospitals. In their recent report the Royal College of Surgeons has overestimated the requirements that a British district general hospital would have of a regional trauma centre.     

Establishment and Use of a General Practitioner Medical Unit in a District General Hospital

An analysis of the establishment and running of a general-practitioner medical unit in a district general hospital has shown that it fulfills a useful and positive role in the area health services and is well used. It shows that selectivity of admission can and does work and that the theoretical drawbacks to such a unit did not materialize in practice during the study.